From the American College of Surgeons, Chicago, Illinois (J.B.L., Y.L., M.E.C., C.Y.K.); the Department of Surgery, University of Chicago Medicine, Chicago, Illinois (J.B.L.); the Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California (C.Y.K.); and the Department of Anesthesiology, Northwestern University, Chicago, Illinois (B.J.S.).
Anesthesiology. 2018 Feb;128(2):283-292. doi: 10.1097/ALN.0000000000002024.
Current preoperative cardiac risk stratification practices group operations into broad categories, which might inadequately consider the intrinsic cardiac risks of individual operations. We sought to define the intrinsic cardiac risks of individual operations and to demonstrate how grouping operations might lead to imprecise estimates of perioperative cardiac risk.
Elective operations (based on Common Procedural Terminology codes) performed from January 1, 2010 to December 31, 2015 at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program were studied. A composite measure of perioperative adverse cardiac events was defined as either cardiac arrest requiring cardiopulmonary resuscitation or acute myocardial infarction. Operations' intrinsic cardiac risks were derived from mixed-effects models while controlling for patient mix. Resultant risks were sorted into low-, intermediate-, and high-risk categories, and the most commonly performed operations within each category were identified. Intrinsic operative risks were also examined using a representative grouping of operations to portray within-group variation.
Sixty-six low, 30 intermediate, and 106 high intrinsic cardiac risk operations were identified. Excisional breast biopsy had the lowest intrinsic cardiac risk (overall rate, 0.01%; odds ratio, 0.11; 95% CI, 0.02 to 0.25) relative to the average, whereas aorto-bifemoral bypass grafting had the highest (overall rate, 4.1%; odds ratio, 6.61; 95% CI, 5.54 to 7.90). There was wide variation in the intrinsic cardiac risks of operations within the representative grouping (median odds ratio, 1.40; interquartile range, 0.88 to 2.17).
A continuum of intrinsic cardiac risk exists among operations. Grouping operations into broad categories inadequately accounts for the intrinsic cardiac risk of individual operations.
目前的术前心脏风险分层实践将手术分为广泛的类别，这可能不能充分考虑个别手术的内在心脏风险。我们试图确定个别手术的内在心脏风险，并展示将手术分组可能导致围手术期心脏风险估计不准确。
研究了 2010 年 1 月 1 日至 2015 年 12 月 31 日期间参加美国外科医师学院国家手术质量改进计划的医院进行的择期手术（基于常见手术术语代码）。围手术期不良心脏事件的综合指标定义为需要心肺复苏的心脏骤停或急性心肌梗死。通过混合效应模型控制患者组合来确定手术的内在心脏风险。结果分为低、中、高风险类别，并确定了每个类别中最常进行的手术。还使用具有代表性的手术分组来检查内在手术风险，以描述组内变化。
确定了 66 例低、30 例中、106 例高固有心脏风险手术。切除性乳房活检的内在心脏风险最低（总体发生率为 0.01%；优势比为 0.11；95%置信区间为 0.02 至 0.25），而腹主动脉-股动脉旁路移植术的风险最高（总体发生率为 4.1%；优势比为 6.61；95%置信区间为 5.54 至 7.90）。在具有代表性的分组中，手术的内在心脏风险差异很大（中位数优势比为 1.40；四分位间距为 0.88 至 2.17）。
手术之间存在内在心脏风险的连续体。将手术分为广泛的类别不能充分考虑个别手术的内在心脏风险。
